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A 61-year-old man presented with gradual blurring of vision and glare in both eyes for a couple of years, with worsening of the vision in his right eye over the past 2 months. He had no medical history of note. On clinical examination, his visual acuities were 20/80 in the right eye and 20/30 in the left eye, uncorrected. The cornea was clear, and the anterior chamber (AC) was deep in both eyes. He had bilateral mild nuclear sclerosis with round central onion-ring–like posterior opacities. The opacities measured approximately 2 mm in diameter and were marginally larger in the right eye than in the left eye (Figure 1 Figure 1. Right eye with mild nuclear sclerosis and central onion-ring–like posterior opacity. ). In addition, there were 2 curvilinear lines across the right posterior capsule (PC), one of which passed across the lens opacity (Figure 2 Figure 2. Retroillumination view of the right cataract showing 2 curvilinear lines in the area of the posterior lens opacity. ). Fundus examination was normal in both eyes, and the vitreous was clear. Optical coherence tomography (OCT) of the macular and optic nerve in both eyes was normal. The endothelial cell count in both eyes exceeded 2000 cells/mm2. He had been told by a previous ophthalmologist to have bilateral cataracts and was now keen for surgery starting with the right eye. He works as a manager in a large company and is an avid golf player. He is emmetropic and wears spectacles for near work. Optical biometry using predicated posterior corneal astigmatism did not recommend a toric intraocular lens (IOL). He had done his internet research on IOL options and requested trifocal IOLs. What is your surgical plan for right cataract removal? Explain which IOL you would choose to implant. [ABSTRACT FROM AUTHOR]

Purpose To study the effects of anterior capsulotomy diameter and discontinuity on tear threshold load and distension for the technique of continuous curvilinear capsulorhexis (CCC). Setting Singapore National Eye Centre, Singapore, and CapsuLaser Inc., Livermore, California, USA. Design Two separate randomized pairwise cadaver eye preclinical studies. Methods Capsulotomies were performed in 40 cadaver eyes of 20 donors using CCC. The pairwise comparisons were divided into 2 study groups: Study A: Continuous versus discontinuous capsulotomies; Study B: Capsulotomy diameter of 5.0 mm and smaller versus diameters of 5.2 mm and larger. A shoe-tree method was used to apply load to the capsulotomy rim, and the Instron tensile stress instrument measured threshold load and distension to initiate a capsular tear. Wilcoxon matched-pairs signed-rank tests were performed to assess statistical superiority. Results In Study Group A, all pairs demonstrated that continuous capsulotomies were better than discontinuous capsulotomies for both the anterior tear threshold load and distension (P <.01). In Study Group B, 80% of the pairs demonstrated that diameters of 5.2 mm and larger were better than those of 5.0 mm and smaller diameter (P <.05). Conclusions Anterior capsulotomies behave as nonlinear elastic (elastomeric) systems when exposed to an external load and distension. This study demonstrated that continuous circular capsulotomies were more resistant to anterior tears than discontinuous capsulotomies. A point of irregularity or a defect in a capsulotomy rim has a high probability of being the tear initiation point. Furthermore, larger diameter capsulotomies were more resistant to anterior tears than smaller capsulotomies. [ABSTRACT FROM AUTHOR]

We describe a single-stage modification of the continuous curvilinear capsulorhexis that facilitates creation of a well-sized round and centered capsulorhexis in an intumescent cataract. This is done without special instrumentation. The modification is based on overcoming the problem of high intralenticular pressure. It involves physically flattening the central anterior capsule, specifically over the site of puncture, simultaneous puncture and aspiration for decompression, followed by flattening of the midperiphery of the lens where the capsulorhexis can be safely initiated. This minimizes the tendency of capsulorhexis runaway and allows 1-stage creation of a well-sized capsule opening for phacoemulsification. [ABSTRACT FROM AUTHOR]

A technique that uses an implanted intraocular lens (IOL) to create a barrier for the management of posterior capsule rupture is described. When a rupture occurs, surgery is halted and a dispersive ophthalmic viscosurgical device (OVD) injected into the anterior chamber to prevent vitreous prolapse. The remaining nucleus is maneuvered into the anterior chamber away from the pupillary space. The posterior capsule tear is converted into a continuous curvilinear capsulorhexis where possible. Dissociated anterior vitrectomy is performed as indicated, keeping the large nuclear fragments trapped in the OVD-filled anterior chamber. An IOL is implanted in the capsular bag or sulcus with optic capture through the anterior capsulorhexis. Using reduced parameters, phacoemulsification of the remaining fragments is completed over the IOL, which functions as a barrier to seal off the vitreous cavity. Residual nuclear fragments and vitreous are cleared from beneath the optic by placing the vitreous cutter under the optic, recapturing the optic before the instruments are removed from the eye. Financial Disclosure: The author has no financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

A modified suture technique for precise knot placement in the Hoffman corneoscleral pocket technique of scleral fixation is described. Both loops of the polypropylene suture passing from the intraocular device through the sclera and conjunctiva are retrieved from the pocket. A loop of suture is pulled through 3 suture throws made using the second suture loop, forming a half bow. Centration of the intraocular lens (IOL)–capsular bag is checked. If the suture tension is too tight, the surgeon can easily undo the knot of the half-bow knot by pulling it free and can then retie the sliding knot. When the IOL–capsular bag is centered, the suture loop is cut and the free end removed. The second suture end is retrieved from the pocket, and knot tying is completed without further adjustment to the tension. Posterior pressure on the intraocular device centers it and settles the knot within the sclera at the fixation point. Financial Disclosure: The author has no financial or proprietary interest in any material or method mentioned. [Copyright &y& Elsevier]

I describe a technique to manage a subluxated crystalline lens or an in-the-bag posterior chamber intraocular lens (PC IOL) that tilts severely into the anterior or midvitreous cavity. In the absence of intervening vitreous presentation, a 27-gauge needle is inserted via a snugly fitting paracentesis incision to reach the anterior capsule of the posteriorly dislocated cataract or the anterior capsulorhexis rim of the PC IOL without disturbing the anterior chamber stability. With the bevel facing forward, the needle is introduced at an oblique angle and used to gently puncture the anterior capsule of the subluxated lens or insinuate between the fibrosed capsulorhexis rim and the optic of the subluxated PC IOL. The needle tip is brought forward and the anterior capsule grasped by microforceps introduced via another paracentesis wound. An ophthalmic viscosurgical device is then injected into the anterior chamber and the lens stabilized. [Copyright &y& Elsevier]

I describe a technique for managing the posterior polar cataract with a dense nucleus by initially sculpting a central trough to the depth of the polar opacity. The nucleus is partially cracked in the periphery, avoiding the polar opacity, and then chopped into quadrants without rotating. Next, the phaco tip engages the core of the nuclear quadrant while a cleavage plane is manually dissected along the lenticular lamellae using a Nagahara phaco chopper, with the tip rotated slightly so it points somewhat toward the equator of the lens, to a depth estimated to leave a nuclear shell, sparing the polar cataract. The nucleus is peeled away from the outer nucleus shell, which is kept in place by the phaco chopper. The intact nuclear plate is removed last and any capsular defect managed accordingly. This technique minimizes the risk for losing a nuclear fragment into the vitreous cavity. [Copyright &y& Elsevier]

We describe a new explantation technique that allows an intraocular lens (IOL) to be removed through the small incisions used in modern cataract surgery. After the IOL optic is freed from the capsular bag, a Vannas scissors is used to cut it into 3 pieces via a temporal clear corneal incision. A Sinskey hook inserted via a paracentesis located 90 degrees away provides a stabilizing counterforce, preventing optic slippage as the blades of the scissors close. We believe this method provides a simple and effective way to remove IOLs via very small incisions, thereby hastening patient recovery and improving outcomes. [Copyright &y& Elsevier]

Purpose: To report the outcomes of posterior-assisted levitation (PAL) to retrieve nuclear fragments and subluxated intraocular lenses (IOLs). Setting: Singapore National Eye Centre, Singapore, Singapore. Methods: In a retrospective series, the case notes of consecutive surgeries performed by a single surgeon between 1999 and 2006 were reviewed. Posterior-assisted levitation was performed for intraoperative posterior capsule rupture with nucleus–IOL dislocation or for late subluxation of posterior chamber intraocular lenses (PC IOLs). This was accomplished by the pars plana insertion of a needle followed by levitation of the subluxated object. Ophthalmic viscosurgical device injection was not used as an adjunct for levitation. Results: Fourteen patients with PAL were followed for a mean of 18.71 months (range 1 to 79 months). There were 3 cases of dropped nucleus/nuclear fragments, 1 case of intraoperative subluxated PC IOL, and 10 cases of late subluxated PC IOLs. Complications included 1 case of retinal detachment occurring 20 months after PAL and 1 case of cystoid macular edema in a patient with previous anterior uveitis. Best corrected visual acuity was 20/40 or better in all except 3 patients (1 retinal detachment, 1 corneal edema/scarring, 1 unspecified). Conclusion: Posterior-assisted levitation provided an effective, relatively noninvasive means of levitating nuclear fragments and PC IOLs with few complications. [Copyright &y& Elsevier]

We report 2 cases of spontaneous postoperative haptic disinsertion with the Alcon AcrySof® MA60BM posterior chamber intraocular lens (PC IOL). A 14-year-old girl with a history of acute retinal necrosis and pars plana vitrectomy with lensectomy for retinal detachment repair had secondary implantation of a PC IOL in the ciliary sulcus. Three months later, the superior haptic disinserted from the optic and dislocated into the anterior chamber. In the second case, a 22-year-old man had lens aspiration and PC IOL implantation in the capsular bag. One year after surgery, the PC IOL had a similar problem, with the disinserted superior haptic remaining in the capsular bag while the optic and inferior haptic dislocated into the anterior chamber. In both patients, the PC IOLs were exchanged for rigid single-piece PC IOLs. The patients have had no further problems. [Copyright &y& Elsevier]

We report the first case of streptococcal endophthalmitis after uneventful right bimanual phacoemulsification. Microincision cataract surgery is perceived to be minimally invasive as smaller wounds are equated to shortened healing time, increased safety, and reduced risk for postoperative endophthalmitis. Recommendations for modifications in wound construction are discussed. [Copyright &y& Elsevier]

Purpose: To report two cases of retinal detachment in young patients with atopic dermatitis masquerading as acute panuveitis., Design: Retrospective observational clinical case reports., Patients: Patients with atopic dermatitis presenting with acute panuveitis and subsequently diagnosed with retinal detachment at the Singapore National Eye Centre., Methods: A review of the clinical case records., Results: Two young patients aged 19 and 21 years with a history of atopic dermatitis presented with acute unilateral moderately severe panuveitis. Both developed rapidly progressing cataracts that made detailed visualization of the fundus difficult. Hypotony persisted in one eye despite partial response of uveitis to therapy. The other patient developed ocular hypertension when the vision in the affected eye suddenly deteriorated. Both eyes demonstrated partial response to steroid therapy. The diagnosis of shallow retinal detachment with anteriorly located incriminating retinal breaks was made after partial resolution of vitreous haze in one case and on repeated ultrasonography in the other case., Conclusion: A high index of suspicion is required when examining young patients with atopic dermatitis who present with acute panuveitis and a rapidly progressive cataract, which may mask the presence of a shallow retinal detachment.